Beneficiary Designation Form
Cornell University - Active Employees
Basic Life Insurance
Cigna Customer Service Center
administered by McCamish Systems, LLC
PO Box 14577
Des Moines, IA 50306
1.800.231.1193
Facsimile 1.877.435.7181
Collect 515.243.1776 from
Alaska or Outside the U.S.A.
CLEAR FORM
Employee Name:
Current Address:
City:
Social Security Number:
State:
Home Phone:
Zip:
Work Phone:
Please review the back of this form for Guidelines for Designation of Beneficiaries
BASIC LIFE INSURANCE, Cigna Life Insurance Company of New York
PRIMARY BENEFICIARY
DATE OF BIRTH
(FLY-051460)
RELATIONSHIP TO
EMPLOYEE
SOCIAL SECURITY
NUMBER
PERCENTAGE
Total Must = 100%
%
%
CONTINGENT BENEFICIARY
DATE OF BIRTH
RELATIONSHIP TO
EMPLOYEE
SOCIAL SECURITY
NUMBER
PERCENTAGE
Total Must = 100%
%
%
If you need additional space for your beneficiaries - sign, date and attach a separate sheet of paper using the above format.
Primary and Contingent Beneficiaries - Unless you designate a percentage, proceeds are paid to primary surviving beneficiaries in
equal shares. Proceeds are paid to contingent beneficiaries only when there are no surviving primary beneficiaries. If you designate
contingent beneficiaries and do not designate percentages, proceeds are paid to the surviving contingent beneficiaries in equal
shares. Unless otherwise provided, the share of a beneficiary who dies before the insured will be divided proportionately among the
surviving beneficiaries in the respective category (primary or contingent).
Community Property Laws - If you are married, reside in a community property state (Arizona, California, Idaho, Louisiana,
Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as beneficiary, it is
possible that payment of benefits will be delayed or disputed unless your spouse also signs the beneficiary designation.
Spouse Signature:
Owner Signature:
831620 01/2013
Date:
Date:
GUIDELINES FOR DESIGNATION OF BENEFICIARIES
General - Please be sure to include the beneficiary’s full name, social security number and relationship to you. Providing this
information can help expedite the claim process by making it easier to locate and verify beneficiaries.
Minors - While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special
issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance proceeds will
not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the child’s estate.
You may want to obtain the assistance of an attorney in drafting your beneficiary designation.
Trust as Beneficiary - You may designate a trust as beneficiary, using the following form: "To [name of trustee], trustee of
the [name of trust], under a trust agreement dated [date of trust]."
If you wish to designate a testamentary trust as beneficiary (i.e. one created by will), you should recognize the possibility
that your will which was intended to create this trust may not be admitted to probate (because it is lost, contested, or
superseded by a later will). Claim payment delays can result if the beneficiary designation doesn’t provide for this situation.
Domestic Partner - If you wish to designate your domestic partner as your beneficiary, you must complete a beneficiary
form. Otherwise, your death benefit will automatically be paid to the first beneficiary listed as follows who is living at the
time of your death: (1) your spouse; (2) your child(ren); (3) your parents; (4) your siblings; or (5) your estate.
Life Status Changes - We recommend that you review your beneficiary designation when significant life status events
occur, such as marriage, divorce, or birth of a child.
See an Attorney! The above guidelines are general, and are not intended to be relied on as legal advice. Unless your
designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary
designation. A qualified attorney can help assure that your beneficiary designation correctly reflects your intentions, is clear
and unambiguous, and meets legal requirements.
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